How many times have you heard about athletes whose careers ended prematurely because of “bad knees”? I recall one of the most promising hockey players of all time, Bobby Orr — widely acknowledged as one of the greatest of all time — who was sadly forced to retire from the sport at the age of 30 because of knee injuries.
Have you ever heard the expression “being cut off at the knees”? It is an acknowledgment that knee injury is a condition that can have a significant impact on quality of life. It can impair our ability to work in certain vocations and often prevent us from enjoying many simple pleasures and pastimes, such as walking, running, or playing certain sports.
In this article, I would like to present some revolutionary concepts that may help explain some of the underlying causes of knee pain and, by extension, many other painful biomechanical disorders. I also hope to shed light on why some of the approaches currently in use may be helping — or not. This information is based on some of the latest scientific evidence of how the body is constructed at the cellular and molecular levels. I believe a better understanding of how the body responds to injury at the most fundamental level, may provide us with the insights necessary to provide real and lasting solutions.
An Epidemic of Knee Arthropathy
It is estimated that knee pain affects approximately 20% of adults, with women being slightly more affected than men. These statistics tend to increase with age.(1) As practitioners in the field of musculoskeletal therapy, we have limited options to help our patients.
The solutions provided by conventional approaches include anti-inflammatory medication, physical therapy (exercise, electrotherapy, low-level laser therapy, etc.), orthopedic supports, and surgery. Arthroscopic surgery may include meniscectomy, meniscal repair, and cruciate ligament reconstruction. In 2011, approximately one million of these surgeries were performed in the US.(2) Although immediate surgical risk is low, the long-term benefits are not encouraging, when it comes to preventing ongoing deterioration.(3, 4)
Total knee replacement is becoming a quite common surgery, especially among the over-45 demographic. Between 2000 and 2010, there was an 86% increase in the rate of these surgeries. In the US, there were approximately 6 million people with at least one knee replacement. A significant proportion of patients experience complications following surgery, and the rate of failure is high when compared with hip replacement surgery.(5, 6)
When Physics Meets Biology
One consideration that very few acknowledge when considering the high incidence of conditions such as arthropathies of the knee is the unique anatomy of homo sapiens. The upright posture provides us with tremendous advantages — freeing the upper extremities to be able to manipulate the environment (gather food, wield tools, and weapons), presenting a higher profile to deter predators, and the ability to survey our surroundings for potential threats and opportunities. However, one of the main trade-offs is that we are more vulnerable to the laws of physics, namely gravity, inertia, and momentum.
For example, I often begin my presentations to practitioners and the public with the following request, “Put up your hand if you’ve never had a fall. ” So far, no takers.
As a result of this vulnerability, we begin the assault on our bodies at an early age. From the moment we set forth on two toddling legs, this often takes the form of slipping and falling on our knees, among many other boney prominences (hands, elbows, hips, shoulders, and head, to name a few). As we get older, we tend to engage in activities that put us at further risk for injury, such as highspeed and contact sports, motor vehicle collisions, etc.
Bone as Fascia
Simple physics tells us that a structure with a higher density will absorb the force of an injury to a greater degree than a structure with a lower density. For example, if you strike a pillow with a hammer, there will be relatively no sound and little or no evidence of the assault, given that the force is easily dissipated by the loosely arranged structural elements of the filling material. In contrast, the more closely packed molecules in a piece of wood, such as a tabletop, will collide more forcefully with each other and the surrounding air molecules, resulting in a loud noise as these molecules strike our eardrum. As a result of its greater density, the wood will also clearly and permanently demonstrate the effects of the “injury.”
One of the densest substances in the body is bone (in essence, a form of mineralized fascia), making it more likely to absorb the force of an injury. There is now documented evidence that the force of injury can react with the molecular elements within the cells and proteins of bone, causing them to measurably expand (Figure l).(7) My theory is that these changes in bone size might appear as misalignment in the case of vertebral segment (subluxation), when evidence suggests that this is most likely because of asymmetrical enlargement of the one portion of a vertebral segment or segments (Figure 2). Radiological and anatomical investigation appears to support this contention.
Put it to the Test I invite you to verify this for yourself. Measure the size of the patella, the distal head of the femur, the greater trochanter, the proximal head of the tibia, or the proximal head of the humerus on one side versus the other. Do this on yourself or some patients. You can use your fingers or an inexpensive set of calipers (See Figure 3). If you then Squeeze each side of the relatively enlarged structure, you might notice that it is often more tender. You might also notice that the quadriceps or the iliotibial band on the side of the larger femoral head or trochanter is more hypertonic. That is because the larger bone creates more tension on the surrounding soft tissues, which can contribute to joint dysfunction, strain, and pain. After you do this, you might get a sense of why I got excited so many years ago.
Normalization of Bone Size
Case Study:
Steve* is a teenage hockey player who experienced significant pain in his left knee for over two years before treatment. After a series of six treatments, there was a significant change in the size of his knees and a marked reduction in pain. He was subsequently able to return to hockey and resume all his normal activities. His parents remarked how delighted they were as they could once again “hear the sound of Steve running up the stairs,” instead of hobbling slowly and painfully as he had for the previous two years.
When comparing the two sets of X-rays of Steve’s knees below (taken two months apart), there was a measurable reduction in the size of the femur and tibia in the left knee. Actual measurements by orthopedic specialists monitoring the condition confirmed a reduction in the width of the femoral distal epiphysis and the tibial proximal epiphysis of almost .5 cm. Note also that the medial aspect of the joint space has also been restored (Figures 4, 5 below).
*Steve, not the real name of the individual described above, is used here to protect the identity of this patient.
The crucial takeaway here is that bone is surprisingly plastic. On the one hand, it can instantly become enlarged due to injury (impact or strain). While on the other hand, it can be restored to normal size using a surprisingly gentle yet targeted approach, often with only a few sessions.
When the bones of the knee (distal femoral epiphysis, proximal tibial epiphysis, and patella) are enlarged and distorted, the underlying articular structures (meniscus, articular cartilage, intrinsic ligaments) are under significant mechanical stress and thus subject to inflammation and degeneration. That often leads to what many orthopedic specialists refer to as the “bone-on-bone” status that sets the stage for the inevitable surgical solution. However, as you can see from the radiographs above, nothing is engraved in stone — or bone!
The Role of Stability
Another major contributor to arthritic degeneration in the knee and many other joints is instability. Many people resort to external stabilizing devices to reduce strain and pain. The marketplace is flooded with a wide range of these devices, and sadly, it has almost become a “badge of honor” to wear them as a signal that you are a serious contender in certain sports.
In the mid-1990s, I discovered a mechanism that I refer to as the A rticular Stability Reflex (ASR), which explains how the loss of stability in certain joints may contribute to the development of pain and articular degeneration. Muscles that provide dynamic stabilization, such as the popliteus and medial hamstrings in the knee (Figure 6),(8) supraspinatus in the shoulder, gluteus medius in the hip, tibialis anterior (ankle), and multifidus and rotatores (lower lumbar spine), are literally turned off in response to certain injuries. I speculated that this mechanism would have the effect of mitigating the transfer of additional strain to certain core structures, including the spinal cord, by creating a “wobble zone ” in these peripheral joints, which I refer to as sacrificial joints. It is important to note that the spinal cord is not present in the lower lumbar spine, which might explain why it is also sacrificed, so to speak.
Programs to strengthen muscles associated with these unstable joints have been promoted to counteract this response. However, I contend that it is impossible to strengthen them because they are essentially denervated, i.e., turned off. That would be like repeatedly changing the light bulb in a lamp that is not plugged in.
The resultant instability may play a role in the degeneration in the knee by increasing mechanical stress on various articular elements and the subtending bone. Our experience has demonstrated that treatment of the structures, which initiated the ASR and are often remote from the dysfunctional joint, can almost immediately reestablish normal tone and function of these stabilizing muscles and literally restore joint stability, like turning on a light switch. The reestablishment of joint stability often contributes to almost instant pain relief and rapid resolution of joint dysfunction.
Summary
Our assumptions about the causes of many structural conditions, including knee pain, may need to be revisited in light of new revelations about the underlying structure of the body and how it responds to injury at the most fundamental level. Our understanding of the consequences of physical trauma in the form of impact or strain has evolved significantly in the past 50 years, and it is essential that we adapt our clinical interventions to incorporate these discoveries. We owe it to ourselves and to our patients to strive to achieve the lasting and profound solutions that are now within our grasp.
Dr. George Roth, BSc, DC, ND, CMRP is recognized as an authority and pioneer in the field of physical medicine. He is the developer of Matrix Repatterning, a breakthrough treatment system that is recognized worldwide. He is the author of The Matrix Repatterning Program for Pain Relief and his contribution to the treatment of concussion and traumatic brain injury has been acknowledged by Dr. Norman Doidge in his best-selling book, The Brain's Way of Healing.
References
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2. Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: a comparison of national surveys of ambulatory surgery, 1996 and 2006, Journal of Bone & Joint Surgery. 2011.
3. Behery OA, Suchman KI, Paoli AR, Luthringer TA, Campbell KA, Bosco JA. What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy? Knee Surg Sports Traumatol Arthrosc. 2019.
4. Friberger Pajalic K, Turkiewicz A, Englund M. Update on the risks of complications after knee arthroscopy. BMC Musculoskelet Disord. 2018.
5. Williams SN, Wolford ML, Bercovitz A. Hospitalization for total knee replacement among inpatients aged 45 and over: United States, 2000-2010. NCHS data brief, no 210. Hyattsville, MD: National Center for Health Statistics. 2015.
6. Wylde V, Beswick A, Bruce J, Blom A, Howells N, Gooberman-Hill R. Chronic pain after total knee arthroplasty. EFORT Open Rev. 2018;3(8):461-470. 2018.
7. Fantner GE, Hassenkam T, Kindt JH, Weaver JC, Birkedal H, Pechenik L, Cutroni JA, Cidade GA, Stucky GD, Morse DE, Hansma PK. Sacrificial bonds and hidden length dissipate energy as mineralized fibrils separate during bone fracture. Nat Mater. 2005 Aug;4(8):612-6. Epub 2005 Jul 17.
8. Electromyographic Study of the Popliteus Muscle in the Dynamic Stabilization of the Posterolateral Corner Structures of the Knee, K Schinhan, et al, Am J Sports Med, Vol. 39, no. 1, 173179, January 2011.
